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�2 v� SiQN,�JOQQU N Environmental Health Department <br /> COUNTY— <br /> hr001-ess grr V5 "ere, <br /> 10, 1 am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br /> �4�5'Fif food is used the following day, maintain below 41°F temperature): <br /> hests ❑ Refigerator <br /> ❑ Refrigerated truck ❑ Ice bath and tubs <br /> Other(specify) - <br /> 11, 1 am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br /> ❑ Three compartment sink. <br /> OR <br /> QTh,ree deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br /> sgkrfion (one tablespoon of bleach per gallon of water). <br /> S] Detergent, bleach, and wiping cloths (cleaning towels). <br /> ❑ Tub to store wiping cloths in bleach solution. <br /> 12. 1 am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br /> booth: <br /> Water supply dispenser with warm water at a minimum of 1007 (i.e. 5-20 gallon container with spigot). <br /> ❑ One separate tub (bucket or basin) for the collection of rinse/wastewater, <br /> ❑ Paper towels and purnp-styie soap container. <br /> 13. Names of responsib a persons to be present in booth during ail hours of operation: <br /> 7 ' / - - <br /> "Important`* All food vendor booths are subject to inspection. Please make a copy of this application in <br /> preparation for this event. A copy of this checklist must be in the booth at all hours of <br /> preparation and operation. Return on final to fee 'yal coordinator three weeks prior to <br /> 14. Completed by: <br /> this a t. Z <br /> ^ 2 S <br /> ^ <br /> Signature Title <br /> 5-20 Gal ate <br /> Hand wasn Water <br /> Healttl PO�rlllt StempwfGhafinq <br /> Dish Paper lian0 Towels <br /> Soap dispenSBr <br /> Saniuxer buCket- <br /> Cutting Board bleach 5 waver for <br /> storing wiping doths <br /> Bteacn <br /> propane Store <br /> � Booth must be on <br /> Conuete,Aspnaft. <br /> Plywood.or a Tarp. <br /> x M,, r _ _-MM1:w <br /> Propane Tank <br /> Soap and water Rinsewater 8ieacn ana'�+aler Garbage <br /> Can <br /> Fire Eutinquisher <br /> L <br /> Ice Cooler r 5 Gai hand wasn <br /> Extra Ice Bags d Food -anrarners m6v oe <br /> Wastewater Container <br /> snored 6 mches off of the ground' <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www,sjgovo EVENT rg/ehdPP <br /> o.,..e a nr 11 <br />